Infectious Disease Management: Guidelines for Alaska Schools

179 Pages·2013·2.45 MB·English

State of Alaska

Infectious Disease Management:

Guidelines for Alaska Schools

DIVISION OF PUBLIC HEALTH
AUGUST, 2013 Infectious Disease Management: Guidelines for Alaska Schools| August 2013 | 1
DIVISION OF PUBLIC HEALTH
Section of Women’s, Children’s, & Family Health
Acknowledgements:
This guideline document was developed in collaboration with the Alaska Department of Health & Social
Services, Division of Public Health, School Nursing/School Health Program and the Section of
Epidemiology; the School Health Nurse Advisory Committee; and the Matanuska-Susitna Borough
School District Summer Academy 2010 school nurses.

Guideline contributors: Guideline reviewers:
Patricia Barker, BSN, RN Melissa Boyette, BA
Mary Bell, BSN, RN, NCSN Louisa Castrodale, DVM, MPH
Suzanne Chappelle, RN, BSN Peggy Cobey, RN, ANP, MPH
Donna Cecere, BA Donna Fearey, ANP, MSN
Marcy Custer, MS, RN Jessica Harvill, MPH
Rebecca Hansen, BSN, RN, NCSN Cornelia Jessen, MA
Lois Henderson, RN Carmen Magee, MS, RN
Sherrell Holtshouser, MPH, RN Karen A. Martinek, RN, MPH
Faith Hundley, BSN, RN, NCSN Elizabeth Miller, MEd, BS, RN, NCSN
Karen James, RN, BSN, NCSN Luann Powers, BSN, RN, NCSN
Lisa Jenson, RN, BSN, NCSN Ginger Provo, BSN, RN
Christy Kinter, RN Lori J. Schneider, BSN, RN, NCSN
Marty Langlois, RN Samuel Senft, JD, MPH
Barbara Mercer, BSN, RN, NCSN Barbara Smith, BSN, RN
Kimberly Spink, RN, BSN, CIC Melody Vahl, BSN, RN
Chris Van Cleve, BSN, RN, NCSN Brian Yablon, MD
Robin Waldvogle, BSN, RN, NCSN Geraldine Yett, RN, MSN, CHES
Suzanne Zaw, MSN, RN

Contact Information:
Mary Bell, RN, BSN, NCSN
School Health Nurse Consultant
Department of Health & Social Services
Division of Public Health
Section of Women’s, Children’s, & Family Health
3601 C Street, Suite 322, Anchorage, AK, 99503
907-269-7368 Fax [phone] [email protected]
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TABLE OF CONTENTS
Introduction/Purpose .................................................................................................................................. 6
Definitions ..................................................................................................................................................... 7
Best Practice ............................................................................................................................................... 10
Protocols for:............................................................................................................................................... 12
Developing school policies ............................................................................................................ 12
How infections are spread ............................................................................................................. 12
Contact transmission
Respiratory Route
Common vehicle transmission
Vector-borne transmission

Infection control measures and Prevention ................................................................................. 14
Hand Hygiene
When to wash hands
How to wash hands
Handwashing considerations
Hand Sanitizers
Cough Etiquette ................................................................................................................ 16
Environmental Control ..................................................................................................... 16
What is the difference between cleaning, sanitizing and disinfecting?
Choosing products for cleaning, sanitizing and disinfecting
Bleach Solution
Frequency of cleaning, sanitizing and disinfecting
Other environmental controls and considerations
Bloodborne Pathogens and Universal/Standard Precautions .......................................... 20
OSHA Bloodborne Pathogen Standard
Exposure Control Plan
Universal Precautions
Engineering Controls
Training
Hepatitis B Vaccination
Regulated Waste
Recommended Decontamination Procedure
Post-Exposure Follow-Up
Immunizations ................................................................................................................. 29
State Requirements
Talking with Parents Inquiring About Vaccine Safety and Efficacy
School Staff Immunizations
Further Resources
Tuberculin Screening ....................................................................................................... 33
State Requirements
TB Testing of School Staff
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Mantoux TST
Further Resources

Illness Symptoms and Management of Individuals Suspected of Communicable Disease .......... 35
Symptoms to watch for
What to do when a student has symptoms
When to seek immediate medical care

General Exclusion Guidelines ........................................................................................................ 37
General exclusion of students
School staff exclusion considerations

Reporting Requirements ............................................................................................................... 38

Role of the School Nurse ............................................................................................................................ 38

General Resources ..................................................................................................................................... 39

References .................................................................................................................................................. 40

Specific disease information (*asterisk indicates vaccine preventable) .................................................... 42
Bed Bugs ........................................................................................................................................ 44
Bites - Animal ................................................................................................................................ 47
Bites - Human ................................................................................................................................. 50
Boil / Abscess / Cellulitis ................................................................................................................ 52
Chickenpox (Varicella)* ................................................................................................................. 54
CMV (Cytomegalovirus) ................................................................................................................ 57
Common Cold (Upper Respiratory Virus) ..................................................................................... 59
Dental Caries .................................................................................................................................. 61
Diarrheal Illnesses .......................................................................................................................... 64
Campylobacteriosis .......................................................................................................... 66
Cryptosporidiosis ............................................................................................................. 67
E. coli ................................................................................................................................ 69
Giardiasis ........................................................................................................................... 71
Salmonellosis ................................................................................................................... 73
Shigellosis .......................................................................................................................... 75
Viral Gastroenteritis (Norovirus)....................................................................................... 77
Viral Gastroenteritis (Rotavirus) ...................................................................................... 79
Ear infection ................................................................................................................................... 81
Fever .............................................................................................................................................. 83
Fifth Disease .................................................................................................................................. 85
Haemophilus Influenzae Type B (Hib)* .......................................................................................... 87
Hand, Foot, and Mouth Disease ................................................................................................... 90
Head Lice ....................................................................................................................................... 91
Hepatitis ......................................................................................................................................... 93
A* ...................................................................................................................................... 93
B* ...................................................................................................................................... 95
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C ........................................................................................................................................ 97
Herpes Simplex (Cold Sores/Fever Blisters) ................................................................................... 99
Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) ............... 101
Impetigo ....................................................................................................................................... 104
Influenza*..................................................................................................................................... 106
Lyme Disease and other tick-borne diseases ............................................................................... 109
Measles (Rubeola)*...................................................................................................................... 111
Meningitis (bacterial*, viral) ........................................................................................................ 113
Molluscum Contagiosum ............................................................................................................. 115
Mononucleosis ............................................................................................................................. 117
Mosquito-borne diseases ............................................................................................................ 119
MRSA (Methicillin-resistant Staphylococcus aureus) .................................................................. 121
Mumps* ....................................................................................................................................... 123
Pin Worms .................................................................................................................................... 125
Pink Eye (Conjunctivitis) ............................................................................................................... 127
Pneumonia* ................................................................................................................................. 129
Respiratory Syncytial Virus (RSV) ................................................................................................. 131
Ringworm (Tinea) ......................................................................................................................... 133
Roseola (Human Herpesvirus 6)................................................................................................... 135
Rubella (German Measles)* ......................................................................................................... 137
Scabies ......................................................................................................................................... 139
Sexually Transmitted Diseases ..................................................................................................... 141
Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) (see
above)
Chlamydia ...................................................................................................................... 143
Genital Herpes ................................................................................................................ 146
Genital HPV .................................................................................................................... 148
Gonorrhea ....................................................................................................................... 150
Pubic Lice (Crabs) ............................................................................................................ 152
Syphilis ............................................................................................................................ 154
Trichomonas ................................................................................................................... 157
Strep Throat (Streptococcal Pharyngitis) and Scarlet Fever ........................................................ 159
Sty ................................................................................................................................................ 161
Tetanus* ...................................................................................................................................... 163
Thrush (Candidiasis) ..................................................................................................................... 165
Tuberculosis ................................................................................................................................ 166
Urinary Tract Infection ................................................................................................................ 169
Warts (Emesis) ............................................................................................................................. 171
Whooping Cough (Pertussis)* ...................................................................................................... 175
Yeast Diaper Rash (Candidiasis) ................................................................................................... 177

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I. INTRODUCTION/PURPOSE1, 2, 3
Infectious diseases account for millions of school days lost each year for kindergarten through 12th grade
public school students in the United States. In 2007, 58% percent of children nationwide aged 6-17 years
missed 1-5 school days in the past year because of illness or injury. Alaska statistics for the same
indicator is similar at 56% but has a higher than national rate for children missing 6-10 days of school in
the past 12 months. Professional nurses were first introduced into the educational setting in the late
1800’s for the purpose of prevention and control of communicable diseases in order to reduce
absenteeism. Today the goal of keeping children healthy in schools continues to be an important and
essential responsibility of school health service programs.

Schools inherently foster the transmission of infectious diseases because of the group setting in which
people are in close contact and share supplies and equipment. However, schools can also be
instrumental in keeping their communities healthy by:
 Encouraging sick students and staff to stay home and seek medical attention for severe illness
 Facilitating hand hygiene by supplying soap and paper towels and teaching/encouraging good
hand hygiene and other disease prevention practices
 Vigilantly cleaning and disinfecting classroom materials and surfaces
 Providing messages in daily announcements and other venues about preventing infectious
disease
 Adopting health practices such as safe handling of food and use of standard precautions when
handling body fluids and excretions
 Encouraging students and staff to get annual influenza vaccinations

The purpose of the Alaska Division of Public Health’s Infectious Disease Management: Guidelines for
Schools is to provide the necessary information for school staff to identify and manage a student and/or
staff member with a suspected or confirmed infectious condition in the school setting. These guidelines
are based on current health information and are not intended to substitute individual student medical
advice. Recommendations for handling infectious disease in schools may change as new information
becomes available. The Alaska Division of Public Health, Section of Epidemiology is available to assist
school nurses and other school personnel when infectious disease issues arise and can be reached at
[phone]. The School Health Nurse Consultant, also in the Division of Public Health, is another
resource and may be contacted at [phone]. Local public health nurses are available for infectious
disease consultation as well.

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II. DEFINITIONS4, 5, 6, 7, 8
Body fluids – Urine, feces, saliva, blood, nasal discharge, eye discharge, and injury or tissue discharge.

Bloodborne pathogens – Microscopic organisms that are present in human blood or body fluids (semen,
vaginal secretions, breast milk) and which can cause disease in humans.

Carrier – A person or animal that harbors a specific disease-causing organism within his or her body,
frequently in the absence of symptoms, and that is a potential source of infection to others.

Clean – The mechanical process of removing dirt and debris (e.g. blood, urine, feces) by scrubbing and
washing with a detergent solution and rinsing with water.

Colonization – The presence and multiplication of microorganisms, without tissue invasion or damage,
resulting in a carrier state.

Contagious or communicable disease – an infectious disease caused by a microorganism (e.g.,
bacterium, virus, fungus, parasite) that can be transmitted from individual to individual.

Contamination– The presence of, or reasonably anticipated presence of, a potentially infectious agent in
or on the body, on any item or environmental surface, or in food or water.

Direct contact transmission – direct body surface to body contact and physical transfer of
microorganisms between a susceptible host and an infected or colonized person.

Disinfect – To apply a chemical or physical agent to an article or surface in order to eliminate virtually all
germs, lowering the risk of transmitting disease to humans. Chemical agents are products registered
with the U.S. Environmental Agency (EPA) as “disinfectants.” Heat is an example of a physical agent.

Exclusion – denying school admission of potentially infectious student or staff member or requiring
them to leave if present.

Exposure – Contact with an infectious person, environment, or contaminated item or surface that may
be capable of disease transmission. Exposures are divided into three categories: Percutaneous, mucous-
membrane, and non-intact skin exposure to blood or other body fluids containing visible blood (Class I);
Percutaneous, mucous-membrane, and non-intact skin exposure to body fluids or feces that do not
contain visible blood (Class II); and Exposures of intact skin to blood or other body fluids containing
visible blood (Class III).

Immunity – State of resistance to a communicable disease by a person as a result of an immune
response generated by vaccination, previous infection or by other factors (e.g., maternal antibodies
transferred in utero, antibody preparation made from human plasma such as immune globulin).

Incubation period – The period of time from exposure to an infectious agent to the appearance of the
first symptom(s).

Indirect contact transmission– Contact and transmission of microorganisms by a susceptible person
with a contaminated object (usually inanimate) or environmental surface.
Infectious agent – An organism that is capable of producing infection or infectious disease in humans.
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Occupational exposure – Skin, eye, mucous membrane, or parenteral contact with blood or other
potentially infectious materials that may result from the performance of an employee’s duties.

Period of communicability – The period of time during which an individual may transmit a disease either
directly or indirectly.

Preventive measures – Actions taken to prevent or reduce the transmission of disease from one source
to another.

Regulated Waste– Blood in liquid form, articles and materials such as bandages, paper towels, tissues,
sharps, etc. that are contaminated with blood or body fluids. Materials contaminated with liquid or
semi-liquid blood or body fluids must be capable of releasing infectious substances if compressed or
during routine handling. Bandages that are not saturated to the point of releasing blood or other
potentially infectious materials if compressed would not be considered regulated waste. Items that are
caked with dried blood or body fluids and are capable of releasing these materials during handling are
considered regulated waste.

Reportable disease – Diseases identified by the Alaska Division of Public Health as reportable by health
care providers and laboratories to the Section of Epidemiology.

Sanitize – Use of a chemical process that lowers the number of infectious agents on surfaces or objects
to a safe level. The object or surface must be cleaned first. Sanitizing applies to a wide variety of
housekeeping procedures for bathrooms, tabletops, food preparation surfaces, mouthed toys/objects,
floors, doorknobs and cabinet handles. Sanitization is less rigorous than disinfection.

Sharps – Needles, broken glass, exposed dental wires, and other objects that are capable of puncturing
human skin.

Standard Precautions – Guidelines recommended by the Centers for Disease Control and Prevention
(CDC) to reduce the risk of transmission of blood-borne and other pathogens. Regardless of whether
they contain blood, Standard Precautions apply to blood, all body fluids, secretions, excretions (except
sweat), nonintact skin, and mucous membranes. The precautions are designed to reduce the
transmission of microorganisms from both recognized and unrecognized sources of infection. Standard
Precautions evolved from Universal Precautions with additional standards intended to protect not only
employees but the population of the facility in general. Standard Precautions involve the use of barriers
(i.e., personal protective equipment such as gloves), handwashing, and cleaning and sanitizing surfaces.

Transmission – Transfer or passage of a specific infectious agent either directly or indirectly from a
source person, animal or inanimate object to a susceptible person. Direct transmission occurs when the
infectious agent is transferred by direct contact, i.e., touching, kissing, sexual intercourse, biting or by
direct projection of droplet spread, i.e., talking, sneezing, spitting, coughing, or singing. Indirect
transmission occurs via contaminated objects or materials, e.g., toys, soiled clothing, bedding, cooking
or eating utensils, food, water, or milk.

Transmission-based precautions – Procedures designed for individuals known or suspected to be
infected with or carriers of highly transmissible or epidemiologically important pathogens for which
additional precautions beyond Standard Precautions are needed. There are three types:
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• Airborne precautions (Examples of such illnesses include measles, varicella, tuberculosis)
• Droplet precautions (Examples of such illnesses include meningitis, pneumonia, diphtheria,
mycoplasma pneumonia, pertussis, influenza, mumps, rubella)
• Contact precautions (Examples of such illnesses include infections or colonization with multidrug-
resistant bacteria, respiratory syncytial virus, impetigo, pediculosis, scabies)

Universal Precautions – An approach to infection control used by the Occupational Safety and Health
Administration (OSHA) of the U.S. Department of Labor to protect employees from exposure to all
human blood and other potentially infectious materials. The approach treats ALL human blood and
certain human body fluids (semen, vaginal secretions, breast milk) as potentially infectious for
bloodborne pathogens. Feces, nasal secretions, sputum, sweat, tears, urine, saliva and vomitus do not
pose a risk of bloodborne pathogen transmission unless they contain visible blood or are likely to
contain blood. Universal precautions include avoiding injuries from sharp instruments or devices and the
use of personal protective equipment as barriers to prevent exposure when providing first aid or
handling regulated waste.

Under-immunized – A person who has not received the recommended number or types of vaccines for
his or her age according to the current national and state immunization schedules.

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III. BEST PRACTICE
The Infectious Disease Guidelines for Alaska Schools was developed utilizing information from the
following sources:
 Centers for Disease Control and Prevention http://www.cdc.gov/
 American Academy of Pediatrics: Managing Infectious Diseases in Child Care and Schools, A
Quick Reference Guide, 2nd Edition. Edited by Susan S. Aronson, MD, FAAP and Timothy R.
Shope, MD, MPH, FAAP.
 Federal Laws:
o Occupational Safety & Health Administration http://www.osha.gov/law-regs.html
 State Laws: Available at http://www.legis.state.ak.us/basis/start.asp
o AS 14.30.045 District or school suspension
o AS. 14.30.120. Certificate of physical examination
o AS. 14.30.125. Immunization
 4 AAC 06.055. Immunizations required
o AS. 18.15.370 Reportable disease list
o AS. 18.15.375 Epidemiological investigation
o AS. 18.15.120 – 18.15.149 Tuberculosis control
 4 AAC 60.100 Physical examination for children
 7 AAC 12.566 Infection control
 7 AAC 12.571 Employee health program
 7 AAC 27.005 Reporting by health care providers
 7 AAC 27.016 Right of inspection
 7 AAC 27.213 Tuberculosis skin test
o AS.18.60.880 Needlestick and Sharps Injury Protections for Healthcare Workers
o AS 11.41.434. through 11.41.470 Mandatory Reporting and Alaska Criminal Law
o AS 25.20.025. Examination and Treatment of Minors
 State of Alaska Division of Public Health, Section of Epidemiology
o Epidemiology Procedure Manual
http://www.epi.hss.state.ak.us/pubs/EpiProcManual.pdf
o Conditions Reportable to Public Health
http://www.epi.hss.state.ak.us/pubs/conditions/ConditionsReportable.pdf
o Alaska Tuberculosis Program Manual
http://www.epi.hss.state.ak.us/pubs/webtb/TB_Manual.pdf
o State of Alaska Child Care & School Immunization Requirements Packet
http://www.epi.hss.state.ak.us/id/iz/factsheet/IZReqPacket2010.pdf
o Epidemiology HIV/STD Program http://www.epi.hss.state.ak.us/hivstd/default.stm
o Foodborne & Waterborne Disease Information
http://www.epi.hss.state.ak.us/id/dod/foodwater/default.htm
 National Association of School Nurses
o Position Statement: Infectious Disease in the School Setting
http://www.nasn.org/Portals/0/positions/2011psinfectious.pdf
o Position Statement: Immunizations
http://www.nasn.org/portals/0/positions/2010psimmunizations.pdf
o Position Statement: Pediculosis Management in the School Setting
http://www.nasn.org/Portals/0/positions/2011pspediculosis.pdf
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